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Date run 5/2/00 8:13:08AM SANWQUIN COUNTY PUBLIC HEALTH SEES Report #: 0002 <br /> Run by SDRISCOL Facility Information as of 5/2/00 Page # 1 <br /> Record Selection Criteria: Facility ID FA0010090 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID; OW0008090 Case Number: H06514 New Owner ID <br /> Owner Name: PATRICK HOLLINGSWORTH <br /> Owner DBA• <br /> Owner Address: <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: 209-466-4375 <br /> Mailing Address; PO BOX 997 <br /> Care of• <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0010090 <br /> Facility Name: AAA MACHINE <br /> Location: 121 E LINDSAY ST <br /> STOCKTON, CA 95202 20 <br /> Phone: 209-466-4375 <br /> Mailing Address: PO BOX 997 <br /> Care of: PATRICK HOLLINGSWORTH <br /> Location Code: 01 - STOCKTON APN: 139-070-03 <br /> BOS District: 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0017 90 New Account ID:: <br /> Mail Invoices to; ACC t Gl�'Ori13�>rj '(D �p�(,��( Mail Invoices to; Owner/ a�ilit /Account <br /> Account Name; MA HINE e One) <br /> Account Balance as of 5/2/00: $110.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inacty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PR0510090 EE0000000-SJC OES Active Y N I <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512378 EE0000000-SJC OES Active Y N I <br /> 2220-SM HW GEN<5 TONS/YR PR0514164 EE0000008-BRIGGS Active Y N I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ail tUorproject <br /> specific,PHS/EHD hourly charges associated with this facility or activity will be billed to the party tdenti ted as the BILLING PARTY oil this form. I <br /> also certify that all operations will be performer)in accordance with all applicable Ordinace Codes anitlor Standards and State andlor Federal Laws <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date rn <br /> 1.0.0.89.00 • <br />